Touhy: Ebersole & Hess' Toward Healthy Aging, 8th Edition Case Studies with Suggested Responses Chapter

19: Cognitive Impairment You are a nurse on a busy medical unit in a large metropolitan medical center. At 3:00 PM, you admit an 81-year-old patient to your unit. She is admitted with pneumonia. She decided not to get an influenza vaccine this year and developed influenza followed by pneumonia. Her primary care physician treated her with a course or oral antibiotics, but when she did not improve, he admitted her to the hospital. She has a history of hypertension, hypothyroidism, and osteoarthritis. You complete her nursing admission assessment. She is independent in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and she walks with a steady gait. She is alert and oriented. She is widowed and lives independently in the community. She is a retired surgical nurse. She is easily engaged and talkative. She tells you that you remind her of her granddaughter, who is also a nurse. She tells you that she usually wears eyeglasses but that she dropped them and broke them yesterday and that her daughter is bringing them to be repaired. She also has a hearing aid in place. You orient her to the unit, insert her IV, and administer her first dose of antibiotics. After you give report to the oncoming shift, you stop to say goodbye to her, and she tells you that she will see you tomorrow. When you get report from the night shift at 7:00 AM the following morning, you are surprised by the report. The night nurse reports that the woman has been up all night long, she is agitated, and climbed out of bed, and sustained a fall. In addition, she is incontinent of urine. You immediately go to see her. She is sitting up in bed and has pulled out her IV. She thinks that you are her daughter and states, Please get me out of here. There are bad people here, and they stand and look at you and laugh at you. They tried to poison me. She is not wearing her hearing aid and will not allow you to insert it. You attempt to reorient her with little success. 1. What do you think has happened to the woman? Provide rationale for your answer.

Suggested Answers She is most likely experiencing an episode of delirium. Delirium is a state of acute confusion. It is characterized by anxiety, restlessness, inability to concentrate, sleep disturbances, and psychotic symptoms such as hallucinations. She is anxious and has been up all night, she is restless and climbing out of bed, and she has psychotic symptoms of thinking people are trying to poison or hurt her. 2. What are some possible precipitating factors in her case?

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Acute illness: She has pneumonia. Sensory deficits: She does not have her eyeglasses and is not wearing her hearing aid. Environmental: She is in a new environment, which is likely noisy (busy medical units usually are). Medications: Medications, particularly those with an anticholinergic effect or any new medication, are possible culprits in delirium. We are not given any information regarding medications in the scenario above. Invasive equipment: Any invasive equipment such as an IV line can be a causative factor in delirium because it interferes with normal feedback mechanisms of the body. Pain: Untreated or undertreated pain can be a causative factor in delirium. Although the scenario does not specifically address pain, she has osteoarthritis, which is a frequent source of pain in older adults.

3. What is your first priority for the woman?

Suggested Answers The first priority is to keep her safe. Providing a safe environment for her would include preventing further falls and protecting her from injury. 4. How do you assess for delirium in an older adult?

Suggested Answers There are several instruments available to assess the presence and severity of delirium. In order to be able to detect changes, it is important to know what the persons baseline is. In the above scenario, you had the opportunity to interact with the woman before she became delirious, so you were able to quickly identify that there was a change. The Mini-Mental State Examination (MMSE) is a general test of cognitive status that helps identify mental status impairments. There are several delirium-specific instruments such as the Confusion Assessment Method (CAM) and the NEECHAM confusion scale. It is important to document specific, objective indicators of alterations in mental status rather than just say that the person is confused. 5. List three interventions that you can implement that would help manage the womans delirium and explain how they would help.

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Reorientation: Reorienting her to her surroundings and the staff would help alleviate some of the anxiety of where she is and what is happening to her. Involving family: Calling her daughter and having her reassure her mother might also help relieve some of the anxiety that she is experiencing. Diversional activities: Providing her with some diversional activities such as reading material, soft music, or an activity apron might provide distraction and help calm her. Moving her to a room close to the nurses station: There is no indication in the scenario where the womans room is, but a room close to the nurses station would increase safety in that she could be visually observed frequently. It might also provide reassurance that she is not alone. Maintaining the IV: Camouflage the IV site with either a long-sleeved gown or sweater or wrap it in a dressing. Or, have continuous running IV fluids only when absolutely necessary; otherwise, use intermittent med lock to administer the antibiotics. Falls and injury prevention: Do not use restraints. Restraints will not prevent falls and may in fact cause injury. Other ways to improve safety in the environment include maintaining side rails in a lowered position so the patient can get in and out of bed, removing obstacles in the environment, providing nonskid footwear, ensuring that the bed is in the lowest, locked position, and providing floor mats and possibly even hip protectors.